UFCW & Employers Benefit Trust

UFCW & Employers Benefit Trust New PPO Medical Plan Features

Page 2 The PPO Medical Plan For those members who are covered under the 2007 Collective Bargaining Agreement, there are significant improvements in your health benefits and the PPO Medical Plan. These changes will help you take control of your health and help you make the best use of the many services provided by the Trust Fund. The PPO Medical Plan is a preferred provider organization (PPO) plan that combines a new Health Reimbursement Account (HRA) with comprehensive medical coverage. In addition to paying benefits when you and your family need medical care, this plan is designed to help prevent illness and promote wellness. For most claims, you are responsible for the deductible. After the deductible is met, most remaining expenses are shared between you and the PPO Medical Plan. The Plan pays its percentage of the covered charges and you pay your percentage, your coinsurance. Your HRA can help you pay your expenses (your deductible and coinsurance). Your HRA can even help you pay the copays for your prescription drugs. Read this brochure to learn more about the HRA and how you can get the most out of your health benefits. The PPO Medical Plan gives you: A deductible is a specific amount you are required to pay before the Trust Fund begins to pay its benefits. Available HRA funds are used to pay your deductible. For Premier and Ultra participants, 100% coverage for preventive care services specified in the Plan s Preventive Care Guidelines when you use PPO providers. For Standard participants, adult preventive care is paid at the same level as other non-preventive care services. Well-baby preventive care for dependents up to age 2 is covered at 100% when you use PPO providers. Preventive care for dependent children age 2 and older is paid at the same level as other non-preventive care. Annual HRA funding ranges from $250 to $1,000 per calendar year depending on your coverage level and your benefit plan (see table below). Your HRA dollars can be used to reimburse your prescription drug copays as well as help pay your calendar-year medical deductible and your medical coinsurance. Calendar-year Premier Ultra Standard HRA funding Single Family Single Family Single Family Automatic Funding Jan. 1 $500 $1,000 $400 $600 $250 $350 Max HRQ Incentive $200 $250 $150 $200 $150 $150 Total HRA Funding $700 $1,250 $550 $800 $400 $500 Additional Health Risk Questionnaire (HRQ) incentive of $150, $200 or $250 per year is available if you and your eligible spouse or eligible enrolled domestic partner complete and return a confidential HRQ. The freedom to choose the health care provider you prefer. If you go to a PPO provider, you will have the lowest possible out-ofpocket expense. You are urged to have a primary care physician (PCP) someone who knows you and your health concerns but the Trust Fund does not require you to select, or to have your care coordinated through, a primary care physician. You do not need a referral to see a specialist. Comprehensive medical insurance that pays 70%, 75%, or 85% of PPO provider charges or 50% of the non-ppo Allowable Charges after you meet your calendar-year deductible. An annual out-of-pocket maximum expense limit that protects you from catastrophic health care expenses. After you meet your deductible and annual out-of-pocket coinsurance maximum, the Trust Fund will pay 100% of your covered medical expenses for the remainder of the calendar year. A $2 million lifetime maximum benefit for every covered person. Family coverage under Standard is available for you and your dependent children only. Coverage for your spouse or domestic partner is not available for Standard participants. Courtesy clerks hired after the ratification of the 2007 CBA are only eligible for Standard employee-only coverage. Coinsurance is your percentage of covered charges for your medical services. The percentage remains the same. Coinsur ance amounts paid by you or your HRA do not apply to the deductible.

Page 3 How the PPO Medical Plan works With full coverage for many preventive care services and your HRA, the Trust The annual coinsurance Fund can pay benefits even before you meet your deductible. Here s how it works: out-of-pocket maximum is a limit on When you go to a doctor or hospital, the Trust Fund uses the money in your your expenditures in a calendar year. It HRA to pay your portion (deductible and coinsurance) of your claims. You no longer have copays for emergency room visits and office visits including visits is lower for services received through for mental health, podiatric, chiropractic and acupuncture care. The Trust Fund a PPO provider than for services received will even reimburse you for prescription drug copays from your available HRA through a non-ppo provider. When you dollars. have met your out-of-pocket maximum, the After you meet your calendar-year deductible, the Trust Fund pays a percentage of your covered expenses. Trust Fund will pay 100% of your covered The deductible amount depends on your benefit level and your family status as charges for the remainder of that calendar shown on the chart below. year. The deductible does not apply toward When your HRA funding is exhausted, you are responsible for meeting the rest your annual out-of-pocket maximum. of the deductible and coinsurance amounts. In most cases, any amount remaining in your HRA at the end of the year rolls over to the following year, so you can use it for future covered medical expenses as long as you remain eligible and enrolled in the Plan. Calendar-year Premier Ultra Standard Deductibles Single Family Single Family Single Family In-network $900 $1,850 $950 $2,000 $1,000 $2,300 Out-of-network $1,100 $2,450 $1,150 $2,600 $1,200 $2,900 The Health Risk Questionnaire One of the key features of the new Health and Care Management Program is a confidential annual Health Risk Questionnaire (HRQ). The HRQ is designed by health care experts to help you assess your health and identify possible health risks before they become serious health conditions. Individual results of the HRQ are confidential and are available only to you. Individual results are not available to the Trust Fund office, your employer or your union. Your completed HRQ will not affect your eligibility or benefit payments, but completing and returning it can add money to your HRA. If you complete the questionnaire you will receive: Confidential feedback on your current health and identification of potential health risks (heart disease, high blood pressure or diabetes). HRQ incentive funding. Fund Fact PPO providers will submit claims for you another good reason to use them. How claims are paid using your HRA When you use a PPO provider, your provider will submit claims on your behalf. The medical claim will be processed and eligible medical expenses, including your medical deductible and medical coinsurance, will be paid from your HRA until your HRA is exhausted. The Trust Fund will send payment directly to the provider who submits the claim. After your HRA is exhausted, you will be responsible for paying your providers for your portion of the cost of your care until you meet the remainder of your calendar-year deductible and your out-of-pocket maximum coinsurance. The Trust Fund will automatically reimburse you from your available HRA funds for eligible prescription drug copays. After your HRA is exhausted, you will have to pay your prescription drug copays for the remainder of the year even after you meet your medical deductible and annual out-of-pocket coinsurance maximum. If you use a non-ppo provider who does not file a claim on your behalf, you will be required to pay the provider and submit a claim to the Trust Fund office for reimbursement of the covered amount.

Page 4 Marcus PPO Premier member with single coverage Assumes: care is received from a PPO provider; coinsurance of 85%; and $900 deductible. First Year Marcus receives his initial $500 HRA funding. He returns his annual HRQ. $200 is added to his HRA balance. Marcus starts his 1st year with $700 in his HRA. Marcus has an annual physical exam which costs $100. Preventive Care Benefit pays $100 in full. His HRA isn t used. His HRA balance stays at $700. Marcus pays zero out-of-pocket. Marcus has an office visit for asthma treatment. The cost of the office visit is $200. $200 is applied to the deductible. $200 is paid to the provider by the HRA. His HRA balance is now $500. Marcus pays zero out-of-pocket. Marcus s doctor prescribes four 90-day special generic Copayments for these drugs total $56. His HRA is used to reimburse him for the copayments in full. His HRA balance is now $444. Marcus paid zero out-of-pocket. $444 in HRA funding is carried over to the next year. HRA $ 500 HRA Balance HRQ + 200 Total (balance beg Year 1) $ 700 $ 700 Annual Physical $ 0 $ 700 Office Visit $ 200 $ 500 Rx Copays $ 56 $ 444 (Four 90-day prescriptions) ===== HRA (balance end Year 1) $ 444 Second Year Marcus has $444 carried over from last year. He receives his annual HRA funding of $500. He returns his annual HRQ. $200 is added to his HRA balance. Marcus has $1,144 in his HRA, 2nd year. Marcus has an annual physical exam which costs $150. Preventive Care Benefit pays $150 in full. His HRA isn t used. His HRA balance stays at $1,144. Marcus pays zero out-of-pocket. Marcus has an asthma attack and goes to the ER. ER visit is $1,500 and $900 is applied to the calendar year deductible. His HRA is used to pay his $900 deductible and his 15% coinsurance of $90. The Trust Fund pays $1,500 for the ER visit $510 from the PPO plan and $990 from his HRA. His HRA balance is now $154. Marcus pays zero out-of-pocket. Marcus s doctor prescribes three 90-day special generic Copayments for these drugs total $42. His HRA is used to reimburse him for the copayments in full. His HRA balance is now $112. Marcus pays zero out-of-pocket. His HRA balance of $112 will carry over to the next year. Year 1 Carryover $ 444 HRA Balance HRA 500 HRQ + 200 Total (funds avail. Year 2) $ 1,144 $ 1,144 Annual Physical $ 0 $ 1,144 Deductible for ER visit $ 900 $ 244 (ER Visit $1,500) 15% Coinsurance $ 90 $ 154 ($600 remaining ER bill x 15%) Rx Copays $ 42 $ 112 (Three 90-day prescriptions) HRA (balance end Year 2) $ 112

Page 5 Cindy PPO Premier member with family coverage Assumes: care is received from a PPO provider; coinsurance of 85%; $1,850 deductible. First Year Cindy receives her initial $1,000 HRA funding. She and her spouse return their HRQs. $250 is added to her HRA balance. Cindy starts her 1st year with $1,250 in her HRA. Cindy s family has four annual physicals which cost $500. Preventive Care Benefit pays $500 in full. Her HRA is not used. Her HRA balance stays at $1,250. Cindy pays zero out-of-pocket. Cindy s family has four office visits. Total cost of the office visits is $400. $400 is applied to the deductible. $400 is paid to the provider by the HRA. Her HRA balance is now $850. Cindy pays zero out-of-pocket. Cindy s doctor prescribes six 90-day special generic Copayments for these drugs total $84. Her HRA is used to reimburse her for the copayments in full. Her HRA balance is now $766. She pays zero out-of-pocket. $766 in HRA funding is carried over to the next year. HRA $1,000 HRA Balance HRQ + 250 Total (balance beg Year 1) $1,250 $ 1,250 Annual Physicals $ 0 $ 1,250 Office Visits $ 400 $ 850 Rx Copays $ 84 $ 766 (Six 90-day prescriptions) HRA (balance end Year 1) $ 766 Second Year Cindy has $766 carried over from last year. She receives her annual HRA funding of $1,000. She and her spouse return their annual HRQs. $250 is added to her HRA balance. Cindy has $2,016 in her HRA, 2nd year. Cindy s family has four annual physicals which cost $500. Preventive Care Benefit pays $500 in full. Her HRA is not used. Her HRA balance stays at $2,016. Cindy pays zero out-of-pocket. The family s medical expenses for the year are $2,250, including office visits, lab work and an ER visit. $1,850 is applied to the deductible. $1,850 is paid to the provider by the HRA. The HRA balance is now $166. HRA is used to pay in full the $60 of her 15% coinsurance. The Trust Fund pays the total medical expenses of $2,250 $340 from the PPO plan and $1,910 from Cindy s HRA. Cindy s doctor prescribes six 90-day special generic Copayments for these drugs total $84. Her HRA is used to reimburse her for the copayments in full. Her HRA balance is now $22. She pays zero out-of-pocket. Her HRA balance of $22 will carry over to the next year. Year 1 Carryover $ 766 HRA Balance HRA 1,000 HRQ + 250 Total (funds avail. Year 2) $ 2,016 $ 2,016 Annual Physicals $ 0 $ 2,016 Family Deductible $ 1,850 $ 166 (Family s total health expenses of $2,250) 15% Coinsurance $ 60 $ 106 ($400 remaining expenses x 15%) Rx Copays $ 84 $ 22 (Six 90-day prescriptions) $84 out-of-pocket HRA (balance end Year 2) $ 22

Page 6 Shelia PPO Ultra member with single coverage Assumes: care is received from a PPO provider; coinsurance of 75%; $950 deductible. First Year Shelia receives her initial $400 HRA funding. She returns her annual HRQ. $150 is added to her HRA balance. Shelia starts her 1st year with $550 in her HRA. Shelia has an annual physical exam which costs $150. Preventive Care Benefit pays $150 in full. Her HRA isn t used. Her HRA balance stays at $550. Shelia pays zero out-of-pocket. Shelia has an office visit. The cost of the office visit is $200. $200 is applied to the deductible. $200 is paid to the provider by the HRA. Her HRA balance is now $350. Shelia pays zero out-of-pocket. Shelia s doctor prescribes four 90-day special generic Copayments for these drugs total $56. Her HRA is used to reimburse her for the copayments in full. Her HRA balance is now $294 Shelia pays zero out-of-pocket. $294 in HRA funding is carried over to the next year. HRA $ 400 HRA Balance HRQ + 150 Total (balance beg Year 1) $ 550 $ 550 Annual Physical $ 0 $ 550 Office Visit $ 200 $ 350 Rx Copays $ 56 $ 294 (Four 90-day prescriptions) HRA (balance end Year 1) $ 294 Second Year Shelia has $294 carried over from last year. She receives her annual HRA funding of $400. She returns her annual HRQ. $150 is added to her HRA balance. Shelia has $844 in her HRA, 2nd year. Shelia has an annual physical exam which costs $150. Preventive Care Benefit pays $150 in full. Her HRA isn t used. HRA balance stays at $844. Shelia pays zero out-of-pocket. Shelia has an ER visit which costs $2,300. There is a $950 calendar year deductible of which $844 is paid from her HRA. Shelia pays $106 out-of-pocket to meet the rest of her $950 deductible. Shelia pays $337.50 out-of-pocket for her coinsurance. The Trust Fund pays $1,856.50 for the ER visit $1,012.50 from the PPO Plan and $844 from her HRA. Her HRA balance is now $0. Shelia s doctor prescribes three 90-day special generic Copayments for these drugs total $42. Shelia pays $42 out-of-pocket, because her HRA is exhausted. For the year, Shelia pays $485.50 out-of-pocket. She will receive her annual HRA funding on the next January 1st. Year 1 Carryover $ 294 HRA Balance HRA 400 HRQ + 150 Total (funds avail. Year 2) $ 844 $ 844 Annual Physical $ 0 $ 844 Deductible for ER visit $ 950 $ 0 (ER visit $2,300. $106 out-of-pocket expense for remainder of deductible) 25% Coinsurance $ 337.50 $ 0 ($1,350, remaining ER bill x 25%. $337.50 out-of-pocket expense.) Rx Copays $ 42 $ 0 (Three-90 day prescriptions) $42 out-of-pocket ===== HRA (balance end Year 2) $ 0

Page 7 Dick PPO Ultra member with family coverage Assumes: care is received from a PPO provider; coinsurance of 75%; $2,000 deductible. First Year Dick receives his initial $600 HRA funding. He and his spouse return their annual HRQs. $200 is added to his HRA balance. Dick starts his 1st year with $800 in his HRA. Dick s family has four annual physicals which cost $500. Preventive Care Benefit pays $500 in full. His HRA is not used. His HRA balance stays at $800. Dick pays zero out-of-pocket. Dick s family has four office visits. Total cost of the office visits is $400. $400 is applied to the deductible. $400 is paid to the provider by the HRA. His HRA balance is now $400. Dick pays zero out-of-pocket. Dick s doctor prescribes six 90-day special generic Copayments for these drugs total $84. His HRA is used to reimburse him for the copayments in full. His HRA balance is now $316. He pays zero out-of-pocket. $316 in HRA funding is carried over to the next year. HRA $ 600 HRA Balance HRQ + 200 Total (balance beg Year 1) $ 800 $ 800 Annual Physical $ 0 $ 800 Office Visits $ 400 $ 400 Rx Copays $ 84 $ 316 (Six 90-day prescriptions) HRA (balance end Year 1) $ 316 Second Year Dick has $316 carried over from last year. He receives his annual HRA funding of $600. He and his spouse return their annual HRQs. $200 is added to his HRA balance. Dick has $1,116 in his HRA, 2nd year. Dick s family has four annual physicals and immunizations which cost $1,000. Preventive Care Benefit pays $1,000 in full. His HRA is not used. His HRA balance stays at $1,116. Dick pays zero out-of-pocket. One child has an ER visit which costs $1,250. $950 is applied to the deductible. $950 is paid to the provider by the HRA. The HRA balance is now $166. His HRA is used to pay in full $75 of his 25% coinsurance. His HRA balance is now $91. He pays zero out-of-pocket. Dick s doctor prescribes six 90-day special generic Copayments for these drugs total $84. His HRA is used to reimburse him for the copayments in full. His HRA balance is now $7. He pays zero out-of-pocket. His HRA balance of $7 will carry over to the next year. Year 1 Carryover $ 316 HRA Balance HRA 600 HRQ + 200 Total (funds avail. Year 2) $ 1,116 $ 1,116 Annual Physicals $ 0 $ 1,116 Deductible for ER visit $ 950 $ 166 (ER Visit $1,250) 25% Coinsurance $ 75 $ 91 ($300 remaining ER bill x 25%) Rx Copays $ 84 $ 7 (Six 90-day prescriptions) = HRA (balance end Year 2) $ 7

Page 8 Sandra PPO Standard member with single coverage Assumes: care is received from a PPO provider; coinsurance of 70%; $1,000 deductible. First Year Sandra receives her initial $250 HRA funding. She returns her annual HRQ. $150 is added to her HRA balance. Sandra starts her 1st year with $400 in her HRA. Sandra has an annual physical exam which costs $100. $100 is paid from her HRA and applied to the $1,000 calendar year deductible. Her HRA pays the $100 in full. Her HRA balance is now $300. Sandra pays zero out-of-pocket. Sandra has two office visits. Total cost of the office visits is $200. $200 is applied to the deductible. $200 is paid to the provider by the HRA. Her HRA balance is now $100. Sandra pays zero out-of-pocket. Sandra s doctor prescribes four 90-day special generic Copayments for these drugs total $56. Her HRA is used to reimburse her for the copayments in full. Her HRA balance is now $44. Sandra pays zero out-of-pocket. $44 in HRA funding is carried over to the next year. HRA $ 250 HRA Balance HRQ + 150 Total (balance beg Year 1) $ 400 $ 400 Annual Physical $ 100 $ 300 Office Visits $ 200 $ 100 Rx Copays $ 56 $ 44 (Four 90-day prescriptions) HRA (balance end Year 1) $ 44 Second Year Sandra has $44 carried over from last year. She receives her annual HRA funding of $250. She returns her annual HRQ. $150 is added to her HRA balance. Sandra has $444 in her HRA, 2nd year. Sandra has an annual physical exam which costs $150. $150 is applied to the deductible. $150 is paid to the provider by the HRA. Her HRA balance is now $294. Sandra pays zero out-of-pocket. Sandra has an ER visit which costs $700. There is a $1,000 calendar year deductible of which $294 is paid from her HRA. Sandra pays $406 out-ofpocket to meet the rest of her deductible. Her HRA balance is now $0. Sandra s doctor prescribes three 30-day generic prescription drugs. Copayments for these drugs total $30. Sandra pays $30 out-of-pocket because her HRA is exhausted. For the year, Sandra pays $436 out-of-pocket. She will receive her annual HRA funding on the next January 1st. Year 1 Carryover $ 44 HRA Balance HRA 250 HRQ + 150 Total (funds avail. Year 2) $ 444 $ 444 Annual Physical $ 150 $ 294 Deductible for ER Visit $ 700 $ 0 (ER Visit $700. $406 out-of-pocket expense for remainder of deductible.) Rx Copays $ 30 $ 0 (Three 30-day prescriptions) $30 out-of-pocket HRA (balance end Year 2) $ 0

Page 9 Kim PPO Standard member with family coverage Assumes: care is received from a PPO provider; coinsurance of 70%; $2,300 deductible. First Year Kim receives her initial $350 HRA funding. She returns her annual HRQ. $150 is added to her HRA balance. Kim starts her 1st year with $500 in her HRA. Kim has an annual physical exam. The cost of the service is $100. $100 is applied to the deductible. $100 is paid to the provider by the HRA. Her HRA balance is now $400. Kim pays zero out-of-pocket. Kim s 18-month-old baby has three well-baby office visits. Total cost of the office visits is $300. Preventive Care Benefit pays $300 in full for a child under 2 years old. Her HRA balance stays at $400. Kim paid zero out-of-pocket. Kim s doctor prescribes six 90-day special generic Copayments for these drugs total $84. Her HRA is used to reimburse her for the copayments in full. Her HRA balance is now $316. Kim pays zero out-of-pocket. $316 in HRA funding is carried over to the next year. HRA $ 350 HRA Balance HRQ + 150 Total (balance beg Year 1) $ 500 $ 500 Annual Physical $ 100 $ 400 3 Well Baby Office Visits $ 0 $ 400 Rx Copays $ 84 $ 316 (Six 90-day prescriptions) ===== HRA (balance end Year 1) $ 316 Second Year Kim has $316 carried over from last year. She receives her annual HRA funding of $350. She returns her annual HRQ. $150 is added to her HRA balance. Kim has $816 in her HRA, 2nd year. Kim and her son have annual physicals which cost $225. Her son is now 2 1/2 and no longer eligible for well-baby care. $225 is applied to the deductible. $225 is paid to the provider by the HRA. Her HRA balance is now $591. Kim pays zero out-of-pocket. Kim has $500 in non-preventive care expenses. $500 is paid from her HRA and applied toward the calendar year deductible. Her HRA balance is now $91. Kim pays zero out-of-pocket. Kim s doctor prescribes five 30-day generic prescription drugs. Copayments for these drugs total $50. Her HRA is used to reimburse her for the copayments in full. Her HRA balance is now $41. Kim pays zero out-of-pocket. Her HRA balance of $41 will carry over to the next year. Year 1 Carryover $ 316 HRA Balance HRA 350 HRQ + 150 Total (funds avail. Year 2) $ 816 $ 816 Annual Physicals $ 225 $ 591 Non-preventive care $ 500 $ 91 ($500 in expenses) Rx Copays $ 50 $ 41 (Five 30-day prescriptions) ===== HRA (balance end Year 2) $ 41

Page 10 UFCW & Employers Benefit Trust HRA and HRQ FAQs Health Reimbursement Account (HRA) What is a Health Reimbursement Account (HRA) and how does it work? An HRA is an account from which funds are used to pay your portion of health care expenses not paid by the PPO Medical Plan, such as deductibles and coinsurance, and to reimburse you for prescription drug copays. The Trust Fund office administers the HRA and allocates money to each eligible employee s HRA annually. In most cases, any remaining balance in your HRA as of Dec. 31 carries over to the next plan year if you remain an eligible PPO member. Your HRA is not a bank account and does not accrue interest. You cannot make deposits to it or withdraw funds from it. Who is eligible for an HRA? All Trust Fund PPO members* who are covered under a ratified 2007 CBA and meet the eligibility criteria for benefits as of Jan. 1 will automatically have an HRA established for them. This also includes members who qualify for coverage during a leave such as FMLA or an eligibility extension due to disability. I cover my spouse and my child under my benefits. Do each of them have an HRA? No, an HRA is only established for the covered member; however, their claims will be processed using funds from your HRA. What happens if I first become eligible for Standard benefits after Jan. 1 of any year? Your HRA will be established on the following Jan. 1. No pro-rata amount is allocated for the partial year during which your eligibility for Standard benefits was established. New Standard employees who become eligible on Feb. 1 or later will continue to be covered under their existing plan benefits until Dec. 31. On the following Jan. 1, they will be covered under the new PPO plan benefits, which include an HRA. If I m a Premier member and switch to an HMO, will I still have an HRA? No. HRA funding is not available to HMO members. If there is a remaining balance in your HRA when your HMO coverage takes effect, it can only be used to pay expenses incurred before your PPO coverage ended. You will forfeit any remaining HRA funding that is not used to pay PPO claims. What happens if I have a family status change after my HRA has been funded for the year? When applicable, additional HRA and HRQ funding amounts will be pro-rated from the date of the family status change. You will not lose funding if your family status changes from a higher HRA benefit amount to a lower benefit amount. For example, if your HRA funding is based on family coverage at the beginning of the year, you would not lose that HRA funding if you divorce and move to a single coverage level later in the year. How are funds in my HRA accessed? When the Trust Fund receives medical claims for you or your eligible family members, it automatically uses your available HRA funding to pay your deductible and coinsurance directly to a PPO provider and to send reimbursement for prescription drug copays directly to you approximately three weeks after you incur a copay.

Page 11 You do not have to submit a request for payment of your deductible or coinsurance to be made from your HRA or to be reimbursed for your prescription drug copays. If your benefits are assigned to a non-ppo provider, the reimbursement will be sent directly to the non-ppo provider. What types of expenses cannot be paid from the HRA? Your HRA cannot be used for premium payments (such as COBRA or retiree health and welfare), expenses that are excluded from the medical and prescription drug programs, such as mental health treatment by a non-ppo provider, cosmetic procedures or for non-medical items such as the dental deductible or eyeglasses. It cannot be used to pay expenses that exceed annual PPO benefit limits. (For example: If your chiropractic benefit has a $500 annual benefit limit and your expenses exceed the limit, your HRA funds cannot be used to pay additional chiropractic expenses.) Your HRA cannot be used to pay dental or vision expenses. Is there any limit as to how long I can keep my HRA or the amount that can accumulate? At this time, there is no limit on how long you can keep your HRA (as long as you remain an eligible PPO member), nor is there a maximum amount that can accumulate in your HRA. How will I know my HRA balance? Your HRA balance will be included on every Explanation of Benefits (EOB) you receive from the Trust Fund office. The balance stated on the EOB will reflect the balance as of the date that claim was processed. If you call the Trust Fund office for your HRA balance, you will be told your HRA balance as of the date and time of your phone call. If I have a break-in-service will I lose my HRA? In general, if you return to employment without a change to your previous status and benefits, you will also retain your associated HRA benefits. If you return to employment and are considered a new hire, any previously accumulated HRA amount is forfeited. Health Risk Questionnaire (HRQ) What is a Health Risk Questionnaire (HRQ)? The HRQ is a confidential questionnaire prepared by health care experts and designed to help you identify potential health risks early so they do not become serious health issues. By identifying potential health risks early, you can seek proper care and make necessary lifestyle changes. Keep in mind that by completing the HRQ you will also receive additional dollars in your HRA. Who is eligible for an HRQ? All PPO plan members covered under a ratified 2007 CBA and their enrolled spouses or domestic partners are eligible to complete an HRQ. How do I access the HRQ? All PPO plan members covered under a ratified 2007 CBA and their enrolled spouses or domestic partners will automatically receive a mailing that explains how to access the HRQ online and how to request a paper HRQ. If you complete the HRQ online, you will be able to print your personal results right away. What about pre-existing conditions? Will filling out the HRQ cause a member to have future issues if a condition is identified as pre-existing? No, individual information in your HRQ will not be shared with the Trust Fund, your employer, your union, your health care providers or anyone else. The Trust Fund office will only receive aggregate data that can be used to project health trends. The aggregate data will be used to identify programs that will be beneficial to our members. No Trust Fund Plans have any pre-existing condition limitations or exclusions. *Special provisions apply for two working Trust Fund PPO members with dual coverage and for newly eligible Standard members.

About This Brochure This brochure provides general information about medical benefits provided through the Northern California UFCW & Employers Benefit Trust. It is intended to help you make enrollment and health care decisions that best meet the needs of you and your family. If you have questions or need more information, contact your Union s Benefit Clerks or call the Trust Office: 1 (800) 552-2400 If there is any difference between the information in this brochure and the official benefit plan documents which include collective bargaining agreements the official benefit plan documents govern. Esta publicación proporciona información importante sobre sus beneficios de salud. Si usted tiene dificultad entendiendo lo que dice, por favor contacte su unión local o llame la Oficina de Fondos en (800) 552-2400.